Waikato District Health Board
Introduction
This report records the results of a Surveillance Audit of a provider of hospital services against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008).
The audit has been conducted by The DAA Group Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health.
The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008).
You can view a full copy of the standards on the Ministry of Health’s website by clicking here.
The specifics of this audit included:
Legal entity:Waikato District Health Board
Premises audited:Tokoroa Hospital||Waikato Hospital||Henry Rongomau Bennett Centre||Puna Whiti||Ward OPR1||Matariki Hospital||Rhoda Read Hospital||Taumarunui Hospital and Family Health Team||Te Kuiti Hospital||Thames Hospital
Services audited:Hospital services - Medical services; Hospital services - Mental health services; Hospital services - Geriatric services (excl. psychogeriatric); Hospital services - Children's health services; Hospital services - Surgical services; Hospital services - Maternity services
Dates of audit:Start date: 21 November 2017End date: 23 November 2017
Proposed changes to current services (if any):None
Total beds occupied across all premises included in the audit on the first day of the audit:797
Executive summary of the audit
Introduction
This section contains a summary of the auditors’ findings for this audit. The information is grouped into the six outcome areas contained within the Health and Disability Services Standards:
- consumer rights
- organisational management
- continuum of service delivery (the provision of services)
- safe and appropriate environment
- restraint minimisation and safe practice
- infection prevention and control.
General overview of the audit
Waikato District Health Board (WDHB) provides services to around 390,000 people in the Waikato district and tertiary services to the Midland Region, made up of five district health boards. Hospital services are provided from the Waikato Hospital and rural hospital at Thames, Taumaranui, Tokoroa and Te Kuiti. There are also aged care facilities in Morrinsville and Te Awamutu. Services include medical, surgical, maternity, paediatric, oncology, older persons/rehabilitation, and mental health and addiction services. These inpatient services are supported by a range of diagnostic, support and community based services.
This three-day surveillance audit, against a subset of the Health and Disability Services Standards, included a review of management, quality and risk management systems, staffing requirements, infection prevention and control, and review of clinical records and other documentation. Interviews with patients and their families and staff across a range of roles and departments were completed and observations made. Auditors visited the Waikato Hospital in Hamilton, Thames Hospital, Tokoroa Hospital and the aged care facilities Rhoda Read (Morrinsville) and Matariki (Te Awamutu).
Rhoda Read and Matariki Continuing Care Facilities provide aged residential care (hospital level) and rehabilitation services for up to 64 patients. The services are currently managed by the clinical nurse director. A clinical nurse manager is overseeing the two facilities until a clinical nurse manager is appointed at Matariki. Patients and families spoke positively about the care provided.
This audit identified 20 areas that require improvement across the standards. These relate to privacy, consent, management of complaints, policy review, risk management, adverse events management, family/whanau participation within the mental health service, training and development recording systems, performance reviews, staffing requirements, and clinical records. Within the clinical standards improvements are required related to assessments, planning of patient care, management of medicines and storage of food at the ward level. Aspects of the facilities require attention to ensure they meet the needs of each patient group and regulatory requirements. The management of enablers and restraints, in the general areas of the hospital, requires improvement, as does infection isolation practices and monitoring of antimicrobials.
Since the previous audit, improvements have been made to clinical practice within the mental health and addictions services, countersigning of documentation where necessary, timeliness of service delivery, cleaning of toys, emergency care equipment in the two aged care facilities and the restraint register, addressing six of the previous required improvements. Work has been progressed in most other areas requiring improvement, with further work underway.
Consumer rights
Patients and families/whānau are provided with the information they require at the appropriate times to make informed decisions which includes consent for treatment. Patients in aged residential care services are provided with information about the Health and Disability Commissioner`s Code of Health and Disability Services Consumers` Rights (the Code) and these are respected. Services are provided that support personal privacy, independence, individuality and dignity. Staff interact with patients in a respectful manner.
Communication with patients and family members was reported as being thorough and in a style that could be clearly understood.
Patients were well informed on how to make a complaint and those interviewed knew how to do so.
Organisational management
In January 2015, the DHB undertook a review of the management structure, with one of the many changes being to place the oversight of the quality and risk services at executive level. Since the resignation of the chief executive in October 2017, an interim chief executive (CE) has been appointed.
The quality and risk management systems are well coordinated and managed through several small teams within the overall framework. Good examples of integrated systems were observed, for example, use of the Health Roundtable data linking to the adverse event data and driving improvements. There was good evidence of corrective actions from organisational audits being centrally managed to monitor progress.
Improvement activity was evident at all levels of the organisation, from large projects using the co-design methodology for the rural transfer project, to small ward based initiatives as part of the ‘Releasing time to care’ programme. The improvement activity is supported by the internal audit teams provided through both HealthShare and the quality and risk team audit schedule, with reports on progress and outcomes being reported through to the ward and internally within the hospital. In aged residential care services, the implementation of the ‘Energise for excellence’ project provides a good example of older persons health and rehabilitation services working collaboratively together.
Since the last audit, a new electronic adverse event management system has been adopted across the Midland region, and is being used at the WDHB to monitor adverse events and complaints. The Datix risk management component is being used to record the organisational clinical and non-clinical risks.
Work has been progress to improve the management of the controlled documents by using the Sharepoint platform, rationalising the number and type of documents, and incorporating best practice through tools such as the Lippincott protocols and guidelines.
Training and development opportunities are provided for all roles across the organisation and staff felt well supported in this area. Specific educator roles support a broad array of programmes planned on a yearly basis, offered as either ‘e-learning’ or face to face sessions. Several systems are used to record training that has occurred.
A range of mechanisms are used to ensure that the right numbers of staff are available to meet the changing needs of patients across the services. Good progress has been made in introducing the patient acuity measurement tools to support both daily and longer-term staffing decisions. There has been a positive change in the age demographic across the DHB and several initiatives have helped reduce vacancy rates in areas such as maternity services.
Continuum of service delivery
Patient care was reviewed and evaluated across services, in addition to the in-depth review of four patients using tracer methodology in the areas of mental health and addiction services, maternity, and older person’s health. Four systems tracers were also conducted in relation to management of medication, the deteriorating patient, the prevention of falls, and infection prevention and control. The information gathered from these tracers was supported by additional sampling.
Care is provided by suitably qualified and experienced staff who work in a multidisciplinary manner to provide timely care. Investigations and assessments are undertaken and used to assist with developing patients’ plans of care. Service delivery overall meets the needs of the patients. The falls prevention programme is well established providing numerous initiatives and a reduction in frequency and severity of falls events. Discharge planning is actively occurring. All patients and family members interviewed were complementary about services received and advice ongoing communication with staff is timely and clear.
Policies and procedures provide guidance for staff on medicines management. The national medicine chart is in use. Allergies are assessed and communicated. Clinical pharmacists provide support to all areas. Medicines are stored safely and managed effectively throughout the organisation.
Safe and appropriate environment
In general, the areas were clean, safe and tidy. Where the ‘Releasing time to care’ programme has been introduced, this has supported improvements to be maintained. The organisation is working through various environmental and facilities issues using a planned and considered approach, including for mental health, paediatrics and maternity areas. Testing of electrical and bio-medical equipment is now being well maintained.
Restraint minimisation and safe practice
The organisation has an effective policy on restraint minimisation and safe practice. A Restraint Advisory Committee actively oversees restraint use, education and monitoring based on collation and analysis of verified restraint data. Restraint improvement measures are overseen by the Restraint Advisory Committee with ongoing audits of restraint implementation. The mental health service has a restraint reduction plan supported by implementation of the national training programme, and a focus on de-escalation.
Infection prevention and control
Surveillance for infections is occurring. The surveillance programme is appropriate to the service setting and includes significant organisms (including multi-drug resistant organisms), specific surgical site infections, invasive device related infections, blood stream infections and outbreaks. The surveillance results are communicated appropriately. Monitoring of compliance with prophylactic antimicrobial use is occurring as a component of the surgical site infection surveillance programme.
Waikato District Health BoardDate of Audit: 21 November 2017Page 1 of 7